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Biomecánica, Anatomía y Anatomía y fisiología respiratoria general

Fisiología Respiratoria del
conceptos fisiopatológicos generales
Niño
mecánica respiratoria
Kinesiólogo Claudio Torres Tapia.
Especialista en Kinesiología Respiratoria e Intensiva-DENAKE diferencias adulto y niño
Terapeuta Respiratorio Certificado
PFCCS Instructor
CAVRR- Los Angeles
Estrategias Ventilatorias del RN

Todos entendemos que un niño

es diferente de un adulto….PERO

¿sabemos cuales son las

diferencias?
 Downloaded from fn.bmj.com on May 24, 2012 - Published by group.bmj.com
Ventilator induced lung injury F227

Etapas del Desarrollo del SR Initiation/

chronic
Qualities of
premature lungs
which increase
Ventilator induced
lung injury (VILI)
ventilation
susceptibility to VILI

• Surfactant deficiency
• Premature antioxidant system
ETAPA EMBRIONARIA: Desde el día 26 al 52. Caracterizado por el • Premature lung structure
• Compliant chest wall
desarrollo de la traquea y bronquios principales. Inadequate lung function

Inhibition of
CLD
alveolarisation
ETAPA PSEUDOGLANDULAR: Del día 52 a la semana 16. Caracterizado por Viable premature birth

el desarrollo de la vía aérea de conducción remanente

23 37
Intrauterine cytokine exposure
Lung development phases
ETAPA CANALICULAR: Desde la semana 16 a la 25. Caracterizado por el desarrollo de la red Glucocorticoid treatment
Microvascular

Developmental
Embryonic Glandular Canalicular Saccular Alveolar
vascular y de la forma y estructura de los acinos. maturation (antenatal and postnatal)

process
Insufficient nutrition
Septation and alveolarisation
ETAPA SACULAR: Desde la semana 24 al nacimiento. Caracterizado por el aumento de la Lung and systemic infections

complejidad de los sáculos. 5–7 16–17 24–26 36–38 1–2 2–3 Oxygen toxicity
weeks weeks weeks weeks years years

ETAPA ALVEOLAR: Desde la semana 36 hasta los 3 años. Caracterizado por el desarrollo de Figure 1 The pulmonary injury sequence. The diagram illustrates the effect of ventilator induced injury and other factors on lung development and
their relation to chronic lung disease (CLD). Reproduced from Attar MA, Donn SM. Mechanism of ventilator-induced lung injury in premature infants.
los alvéolos. Semin Neonatol 2002;7:353–60, with permission from Elsevier.

Maduración Pulmonar
RESPIRATORY DISTRESS SYNDROME
RDS is a disorder of the premature lung. Although surfactant
replacement therapy can compensate for the biochemical
abnormalities to a large extent, the morphological abnorm-
alities must be addressed. The lung has insufficient alveolar-
isation and thus diminished functional surface area for gas
exchange. There is an increased distance from the alveolus to
its adjacent capillary, and deposition of fibrin in the air
spaces; both conspire to decrease gas diffusion. Pulmonary
arteriolar muscularisation leads to elevated pulmonary
vascular resistance and diminished pulmonary blood flow,
often accompanied by right to left shunting.
Table 1 lists the goals of mechanical ventilation. These
should be kept in mind no matter what device, mode, or
modality is chosen. Ventilatory strategies range from the least
invasive (CPAP)Arch toDisthe
Childmost
Fetal Neonatal Ed 2006;91:F226–F230.
invasive (extracorporeal
membrane oxygenation), which is occasionally used in the
larger premature infant with intractable respiratory failure.8
CONTINUOUS POSITIVE AIRWAY PRESSURE
First introduced into neonatal practice by Gregory and
colleagues in 1971,8a CPAP is a form of continuous distending
pressure used to maintain some degree of alveolar inflation
during expiration. According to the Law of LaPlace, the
increased radius of curvature requires less pressure to

Generalidades transporte de gases

overcome the surface tension promoting its collapse, and
thus decreases the work of breathing. CPAP as a primary
Vent circuit Overdistension
strategy for the treatment of RDS was popularised by Wung
flow set
and colleagues, who showed a dramatic reduction in CLD
at 5 litres/min
compared with units where mechanical ventilation is often
used.9 Wung et al emphasised the dependence on sponta-
neous breathing, the avoidance of sedatives and skeletal
muscle relaxants, and the acceptance of a wider range of
blood gases and pH. Although this remains an attractive
Intercambiador.
Volume
hypothesis, there is still much controversy surrounding the
use of CPAP. Randomised clinical trials are only now finally
in progress. The best means of providing CPAP are yet to be
determined. The relation of CPAP and surfactant replacement
fonación Vent circuit
therapy is also in need of evaluation. Does the use of CPAP
and the avoidance of intubation delay the effectiveness of
flow set surfactant in those infants who eventually require it? How do
at 8 litres/min the work of breathing and energy expenditure during CPAP

protección 0 Table 1 Goals of mechanical ventilation

0
Pressure (PIP – PEEP) l Overcome alveolar atelectasis
l Achieve adequate pulmonary gas exchange

equilibrio AB Figure 2 Pressure volume loops showing the effects of ventilator circuit
flow on the elastic load. Note the overdistension occurring at the higher
l
l
Decrease the patient work of breathing
Maximise patient comfort
l Avoid ventilator induced lung injury
flow rate, which can be normalised when flow is decreased. PIP, Positive
inspiratory pressure; PEEP, positive end expiratory pressure. Courtesy of

metabolismos/endocrino
V K Bhutani, MD.

www.archdischild.com

Levitzky, 2003
 Ventilator-induced lung injury to physician-in

Lo necesario para una adecuada Homeostasis Gaseosa... First, in the acutely injured lung, o
Whale lung contributes to gas exchange (b
Dugong
100 The diseased lung in patients wi
SLOPE = 1.02 Manatee
Bear Cow ogeneous with collapsed and c
Pig Porpoise mainly in the dependent regions
una unidad funcional para Unidad Alveolo Capilar 10 Goat MAN
units in the non-dependent reg
intercambio Dog
experimental animal data demon
Racoon
not the high pressure per se but

Lung volume (L)

1 Cat
Rabbit Monkey regional tidal volumes (volutraum
Marmot
Parrilla Costal y Musculatura Respiratoria Armadillo compliant areas of the lung, and
una bomba 0.1
associated with the opening and
Guinea Pig
lung regions that damage the lun
Rat goal of mechanical ventilation sho
0.01
‘adequate’ gas exchange rather
un controlador Sistema Nervioso Central y Periférico Lung Volume = 6.3% BW
Tidal Volume = 6.3 ml kg–1 blood gases values within the norm
Mouse
0.001 range. However, following the Con
Shrew
Bat on Mechanical Ventilation little ch
practice occurred around the wo
Capacidad Residual Funcional 0.01
un reservorio 0 .1 1 10
Body weight (kg)
100 1000
recommendations on how to venti
were not the result of any specific
Fig. 1. Scaling of the lung in mammals (adapted from [25,26]). trolled clinical trial.
If the amount and quality of info
gradual loss of lung volume and hypoxaemia due to mechanical ventilation in acutely
right-to-left shunting through regions with poor ven- much greater now than that in 1
tilation. As a result, the one-tidal volume fits-all the current tendency towards the
approach was formulated and inspiratory volumes Although most would agree that w
of 10—15 ml kg!1 were recommended and, for the the culmination of an era in researc
next 20 years, experts and pioneers of critical care studies do demonstrate a decrease

CRF en adultos
medicine continued ventilating patients with ALI the years as tidal volumes have
and ARDS with large tidal volumes and high inspira- (Fig. 2). However, additional rese
tory pressures (27). still needed. We have not clearly
In 1967 the hallmark paper on ARDS by Ashbaugh PEEP in ARDS outcome. There is
et al. (24) showed that the application of PEEP was tory evidence that ventilating A
equilibrio de recorrido elástico entre pulmón y parrilla costal associated with a lower mortality rate in patients with relatively low tidal volumes and h
severe lung injury. In the early 70s, Webb and Tierney is clinically beneficial. A recent e
(28) demonstrated for the first time that high peak has demonstrated that the applica
se alcanza de manera pasiva. alveolar pressure can severely damage the lung and of PEEP, independent of tidal vol
that PEEP can attenuate that damage. There are now
considerable experimental and clinical evidence
aproximadamente 3000 ml. showing that the application of high levels of PEEP 14
in the initial phase of ARDS protect against alveolar 12

mortality
flooding and support gas exchange by maintaining

64%
óptimo intercambio.
10
collapsed alveoli open, increasing end expiratory

VT (mL kg–1)

mortality
8

50%
lung volume and improving compliance. Although
PEEP is an important tool used to facilitate lung 6

garantizada en vigilia, sueño y actividad!!! recruitment and minimize further injury (12, 14, 4
29—31), most critical care physicians are still reluctant 2
to use PEEP levels above 10 cmH2O (23), despite the 0
fact that a low tidal volume can induce alveolar dere- 1978–1981 1986–1989 1993
cruitment (29, 30).
Fig. 2. Schematic representation of the re
In 1994, a Consensus Conference on mechanical temporal reduction of tidal volume and th
ventilation (32) concluded with a set of recommenda- patients with ARDS throughout the last 2
tions based on three important pieces of information. compiled from [9, 17, 18, 34].
 AIRWAY CLEARANCE IN THE ELDERLY AND PATIENTS WITH NEUROLOGIC COMPROMI

Diafragma Table 3. Respiratory Muscles

Inspiratory, primary
Diaphragm
External intercostals
Scalene
Principal músculo
Inspiratory, accessory
respiratorio en mamíferos
Sternocleidomastoid
Trapezius
función de Pistón aumenta AIRWAY CLEARANCE IN THE ELDERLY AND PATIENTS WITH NEUROLOGIC COMPROMISE
Expiratory
Pº negativa intratorácica Internal intercostals Table 3. Respiratory Muscles

Inspiratory, primary

Internal and external obliques Diaphragm

External intercostals
Scalene
Transverse abdominus
Su función se afecta por Inspiratory, accessory
Sternocleidomastoid
Rectus abdominus Trapezius

anatomía torácica Expiratory

Internal intercostals

Upper Airway Internal and external obliques

Transverse abdominus
Rectus abdominus

Abductors of vocal cords Upper Airway

En RNPT menor zona de

Abductors of vocal cords

Palatal elevators Palatal elevators

Retractors of tongue
Dilators of nares

aposición Retractors of tongue AIRWAY CLEARANCE IN THE ELDERLY AND PATIENTS WITH NEUROLOGIC COMPROMISE
Dilators of nares The Muscles of Respiration

The muscles of respiration and those involved with cough

Development of the Thoracic Cage / 127
The Muscles of Respiration
The muscles of respiration and those involved with cough
are often divided into 3 categories: inspiratory muscles,
expiratory muscles,
AIRWAY C LEARANCEand muscles of the upper airways.
Table 3 and Figure 3 review these muscles.
The primary inspiratory muscles include the diaphragm,
FIGURE 9–6. Functional anatomy of the rib cage. A, Zone of apposition. (Reproduced with permission from DeTroyer A and Estenne M.28)
B, Bucket-handle effect. (Reproduced with permission from De Troyer A and Loring SH.29)
are often divided into 3 categories: inspiratory muscles, Fig. 3. The muscles of respiration. (From Reference 75, with per- ventilatory limitations may become evident duri
mission.)
expiratory muscles, and muscles of the upper airways. illness, surgery, or exercise.18 During exercise th
Table 3 and Figure 3 review these muscles. tend to use their abdominal muscles to a greate
The primary inspiratory muscles include the diaphragm,
the external intercostals, and the scalene muscles.74 During the glottis to allow generation of adequate intrathoracic and to use a rapid shallow breathing pattern beca
pressure, and (3) weak expiratory muscles and an inability
exercise and other situations in which additional effort is
required, the accessory inspiratory muscles (sternocleido-
mastoid and trapezius muscles) are recruited.
to generate an adequate intrathoracic pressure. The result
is a limitation of dynamic airway compression and a fail-
rigid rib cage.19 But, despite these ventilatory cha
elderly are still usually limited by circulation be
Expiration is normally a passive maneuver, dependent ure to generate sufficient peak cough flow.8 deconditioning or from changes in cardiovascula
on the elastic recoil of the lung. During exercise or forced A recent clinical practice guideline for airway clearance
expiration, the abdominal muscles are recruited either to therapies reported by the American College of Chest Phy- ology.19 During exercise, the incremental increas
fix or to cause an inward movement of the abdomen and
upward displacement of the diaphragm to assist expiration.
sicians presented a list of 10 recommendations for various
patient populations.77 The recommendations primarily fo-
volume to increase minute ventilation is primaril
recruitment of end-inspiratory lung volume, rathe
The expiratory muscles include the rectus abdominus, trans-
verse abdominus, the internal intercostals, and the internal
cus on patients with chronic secretion problems, such as in
cystic fibrosis, chronic bronchitis, bronchiectasis, and
Fig. 3. The muscles reducingofend-expiratory
respiration. (From
lung volume Refe
as seen in
dations were specific for patients with neuromuscularmission.)
and external obliques.75 chronic obstructive pulmonary disease, but 3 recommen- individuals.42
The muscles of the upper airways help to maintain pa-
INthat
tency so THE E
LDERLY
air can flow in and outAND PATIENTS
of the lungs without W ITH
ease (TableN4).EUROLOGIC
Note, however, thatC OMPROMISE
the 3 recommendations
dis-
With aging, the ventilatory response to hypo
obstruction. Muscles of the upper airway include the ab- (expiratory muscle strength
Fig. 1. Relative changestraining, manual
in lung cough assist,
volume associated with aging. hypercarbia is blunted, most likely due to a combi
ductors of the vocal cords, the retractors of the tongue, the
palatal elevators, and the dilators of the nares.70,76
and mechanical cough assist) have relatively low-grade
IRV ! inspiratory reserve volume. VC ! vital capacity. TV ! tidal
supporting evidence. The grading scale employed suggests
a reduced neural output to the respiratory muscl
volume.
(1) theERV expiratory
! for reserve volume. FRC ! functional re- creased peripheral chemosensitivity, and a lower
that support the recommendations is based on
Airway Clearance Techniques for Patients ventilatory siduallimitations
low-level capacity. RVmay
evidence (nonrandomized,become
! residual volume. evident
case-oriented, (From during acute
or ob- Reference 19, with ical efficiency and deconditioning.45,46 Minute ve
With Neuromuscular Disease

the external intercostals, and the scalene muscles. During

illness, surgery,
permission.)
servational or the glottis to allow generation of adeq
exercise.
studies)
74
efit is believed
During
or on expert18opinion, (2) theexercise
net ben-
to be small (there is evidence of benefit that
the elderly response to elevated carbon dioxide during hypo
In patients with neurologic and neuromusculartend
disease,to use
may nottheir
clearlyabdominal
exceed the minimum muscles to a greater degree
clinically important duced during exercise in the elderly, compared to
cage (Figure 9–6A). Third, the diaphragm acts to elevate compliant chest wall of the infant results in a less efficient
an ineffective cough is the main reason for mucus reten-
exercise and other situations in which additional effort is and to use
tion.73 Ineffective cough is primarily due to (1) weak in- some a evidence pressure, and (3) weak expiratory muscle
benefit) or intermediate (clear evidence of benefit but with
rapid ofshallow
harm), andbreathing pattern because of a
(3) the recommendations
individuals.47 Respiratory response to both hypox
spiratory muscles and an inability to take a deeprigid
breath,rib cage. 19 But, despite
grade of Cthese ventilatory changes, the hypercarbia is decreased by 40 –50% in a healthy
to generate an adequate intrathoracic pre
the lower ribs through its area of apposition to the inner respiratory pump. By decreasing pleural pressure, the res- have a final evidence (weak recommendation)

required, the accessory inspiratory muscles (sternocleido-

(2) impaired bulbar function and a reduced ability to close or E/C (weak recommendation based on expert opinion).78 old.45,46
rib cage wall. This elevation of the lower ribs also expands piratory muscles, inwardly distort the chest wall. This can elderly are still usually limited by circulation because of
lower thoracic cross-sectional area by causing the down- result in diaphragmatic pressure-volume work exceeding
ward-sloping ribs to assume a more horizontal position, pulmonary work by up to sevenfold.32
mastoid and trapezius muscles) are
deconditioning or from changes in cardiovascular
2007 V recruited.
52 ology.
is a limitation physi- of dynamic
Clinical Implications airway compr
the “bucket-handle” effect (Figure 9–6B). While the mechanical inefficiencies of the infant chest R C •O
ESPIRATORY ARE N 10
CTOBER
During exercise, the incremental1367
OL O 19 increase in tidal
minute ventilation is ure to duegenerate sufficient peak coughchange flo
The differences between the adult and infant chest wall wall may interfere with the diaphragm’s ability to generate
outlined above can affect the diaphragm’s inspiratory pressure, these inefficiencies may be overcome by the law Expiration is normally a passive maneuver, volume to increase dependent primarily
recruitment of end-inspiratory lung volume, rather than to
to Despite the physiologic and functional
ated with aging (Table 2), the basal function of mo
action. Since less of the rib cage’s contents are intra-
abdominal, and the area of apposition is less in the infant
of Laplace. This law states that the smaller radius of cur-
vature of the infant’s diaphragm relative to the adult
on the elastic recoil of the lung. Duringreducing exercise or forced
end-expiratory
A recent clinical
lung volume as seen in younger
practice
systems, including guideline
the respiratory system, is for
relat
than in the older child and adult (Figure 9–7),30,31 there is should improve its pressure generating ability at a given

to response therapies reported

tomatic by the American Colle
compromised. The healthy elderly individual is 63

expiration, the abdominal muscles areindividuals.

42
recruited
With aging, theeither
a diminished bucket-handle effect. In addition, the highly level of tension. In fact, maximal inspiratory occlusion
at rest, but functional reserve and the a
ventilatory to hypoxia and
likely due to sicians presented a list of 10 recommend
compensate for various physiologic stressors is re
fix
Fig. or tochanges
1. Relative cause anvolume
in lung inward movement
associated with aging. of the abdomen
hypercarbia is blunted, most and a combination of Stressors that might challenge the elderly beyo
a reduced neural output to the respiratory muscles, a de-
IRV ! inspiratory reserve volume. VC ! vital capacity. TV ! tidal
upward
volume. displacement
ERV ! expiratory ofFRCthe
reserve volume. diaphragm
! functional re- to assist
creased expiration.
peripheral
patient populations.
chemosensitivity, and a lower mechan-
77 The
reserve include
recommendat
pneumonia, surgery, and exacerba
comorbid condition, such as asthma, chronic ob
sidual capacity. RV ! residual volume. (From Reference 19, with
The expiratory muscles include the rectus
permission.)
Fig. 2. Changes
ical efficiency
abdominus,
in lung volume over time.
and deconditioning.
with permission.) trans-
cus on patients
(From ventilation
Minute Reference 15,
with
pulmonary
45,46
chronic secretion
disease, or congestive
of the elderly to specific medications and to comb
proR
heart failure.
response to elevated carbon dioxide during hypoxia is re-
verse abdominus, the internal intercostals, and the
duced during internal
exercise in the elderly, compared cystic fibrosis,
to younger chronic
of medications bronchitis,
can also be an issue. Lean body
total body water is decreased while body fat is inc
brom
and external obliques. 75 in theRespiratory
individuals.
hypercarbia
dependent part
is decreased
worsens
response
47 to both
of the lung chronic
hypoxemia
during
by 40 –50% inrelationship
the ventilation-perfusion
obstructive
and
tidal breathing
a healthyand 70-year-
is asso-
the elderly,pulmonary
which alters the volume disease,
of distribu
redistribution and the clearance rates of drugs, so d
The muscles of the upper airways help old. tociated maintain
carbon pa- Carbondations
with a reduction in oxygenation
45,46
monoxide transfer.
were specific
and diminished
dioxide elimination 16,39
not eliminatedfor patients
as well as they are inwith
youngerne
The aging process is also associated with chang
p

tency so that air can flow in and out of the appears

Clinical lungs
Implications without
to be unaffected, despite a slight ease (Table
increase in the 4).central
Note, however,
nervous system, which that
increases the 3
the sens
dead-space ventilation ratio. 40,41
the elderly patient to many anesthetic agents. 65

obstruction. Muscles of the upper airway include

Despite the deterioration
This age-related ab- (expiratory
in lung function is slower muscle patients arestrength
approximately training,
30 –50% more ma sen
in the physiologic
those and functional
with a long-term changes
habit of exercise, butassoci-
it is not propofol than are younger patients. 65,66
FIGURE 9–7. Area of apposition of the diaphragm in the newborn (A) and adult (B). The area of apposition is small in the infant and large in the
adult. (Adapted from Devlieger H.30)
ductors ofCARE
RESPIRATORY the •vocal
OCTOBER cords,
2007 VOLthe52retractors
NO 10 atedof
withthe
aging
abated,tongue,
(Table
even in 2), the
elitethe basal function
athletes. and of most mechanical
organ 42,43 coughrespiratory
A particular assist) concern have rela
is the increase
systems, including the respiratory system, is relatively un- aspiration and pneumonia. Anesthetics and m 19,67

palatal elevators, and the dilators of the nares.

compromised.
70,76
Exercise and healthy
The Ventilatory Response
elderly
63 supporting
individual is asymp- evidence. The pharyngeal
laxants compromise grading scale
function and dime
tomatic at rest, but functional reserve and
Younger normal individuals are limited thatin (1)
the ability
exercisetheby support
to
elderly. forThe theelderlyrecommenda
effectiveness of the cough mechanism, especial
are also more susce
63,67,68
compensate for various physiologic stressors is reduced. 18

Airway Clearance TechniquesStressors circulation, not ventilation.

for Patients low-level
Because of the changes
theirevidence (nonrandomized, cas
drug interactions that can result in respiratory de
19,44
that might
already challenge
discussed, the elderly
the ventilatory reserve beyond
is compromised (eg, an analgesic that contains codeine with an a
reserve include pneumonia, surgery,not andapparent
exacerbation
at rest, of a
With Neuromuscular Disease in the elderly, and although
comorbid condition, such as asthma, chronic obstructive
servational their
studies) or on expert opinion
mine or a ! blocker). Because of these issues, th

Fig. 2. Changes in lung volume over time. (From Reference 15,

with permission.)
pulmonary disease, or congestive heart failure. efit isResponsebelieved to be small (there is eviden
of the elderly to specific medications
• OCTOBER and 2007toVcombinations
also be an issue. Leanmay notand clearly exceed the minimum cli
RESPIRATORY CARE OL 52 NO 10
In patients with neurologic and neuromuscular of medications candisease, body mass

Desarrollo de la Caja Torácica
Osificación desde vida intrauterina hasta los 25 años
Calcificación de los cartílagos costales hasta la vejez.
la pared torácica se “endurece con la edad”
la C pulmonar sufre escasos cambio con el crecimiento.
la C torácica disminuye progresivamente.
la C torácica 2 a 6 veces mayor que la C pulmonar en los infantes (mayor
diferencia en RNPT)
Adultos y adolescentes se igualan ambas C.
Osificación y masa muscular condicionan cambios (eficiencia y función)
A B
C D
FIGURE 9–2. Changes in rib cage morphometry with growth. A, Posteroanterior and B, lateral chest radiographs of a 4-month-old infant. C,
Posteroanterior and D, lateral chest radiographs of a 14-year-old male. In the infant the slope of the ribs is nearly horizontal, while in the 14 year
old there is a downward declination of the ribs. (Reproduced with permission from Allen JL, Wohl
In: Taussig LM, Landau LI, editors. Pediatric respiratory medicine. New York: Mosby 1999.) Posteroanterior and D, lateral chest radiographs of a 14-year-old male. In the infant the slope of the ribs is nearly horizontal, while in the 14 year
old there is a downward declination of the ribs. (Reproduced with permission from Allen JL, Wohl MEB. Neuromuscular and chest wall disorders.
In: Taussig LM, Landau LI, editors. Pediatric respiratory medicine. New York: Mosby 1999.)
176 / Basic Mechanisms of Pediatric Respiratory Disease
FIGURE 12–5. Ratio between the compliance of the chest wall and that of the lungs in newborn and adult mammals of several species. The
values represent averages compiled from various studies. ■ = ratio in newborns; /!
// = ratio in adults. (Adapted from Mortola JP,11 which includes
references for the individual species.)
DEVELOPMENT OF THE THORACIC CAGE JULIAN ALLEN, MD, KAREN W. GRIPP, MD
Pediatric Respiratory Disease.Chernick-Mellins, 2002
high viscous characteristics of the neonatal pulmonary than the corresponding passive values, with the result of
tissue and, possibly, due to some peripheral airway shortening of the response time of the system.
closure determined by lung deformation.9,20,21 How much
Development of the Thoracic Cage / 125
higher is the muscle pressure required to breathe, com-
Development of the Thoracic Cage / 125 pared with the passive measurements, cannot be said with EXPIRATION
certainty, because estimates are very indirect.10 In infants During the second phase of the breathing cycle (ie, expi-
during active breathing the effective compliance could be ration), two mechanisms are the primary factors modify-
only about half of Crs.22 ing the mechanical behavior of the respiratory system:
Changes in rib cage morphometry with
growth. A, Posteroanterior and B, lateral
Resistencia= ∆ Presión/flujo
The functional implication of an effective reduction in
Crs during breathing is that the response time of the sys-
the postinspiratory activity of the inspiratory muscles
l = largo
and the laryngeal control of expiratory flow. The latter
tem is shorter than τrs. Furthermore, pulmonary resis- consists in the narrowing of the vocal folds during expi-
chest radiographs of a 4-month-old infant.
C, Posteroanterior and D, lateral chest tance can decrease during breathing to below the value u= viscosidad
ration, a physiologic phenomenon that can be exagger-
measured in passive conditions. Indeed, when pulmonary ated in conditions of respiratory distress into what is
radiographs of a 14-year-old male. In the
infant the slope of the ribs is nearly
tissue viscosity is high and is an important contributor to V = flujo
known clinically as “grunting.” These two mechanisms
the total resistance (as is the case in newborn lungs), Rrs prolong the time required for deflation, such that the
horizontal, while in the 14 year old there is a
downward declination of the ribs.
does not increase; in fact, it actually decreases with r = radio
expiratory time constant (τexp) is longer than τrs. In the
breathing rate.23 In the newborn opossum, mouse, and human infant, for example, at the normal breathing rate,
(Reproduced with permission from Allen JL,
Wohl MEB. Neuromuscular and chest wall
hamster,18 this mechanism has been estimated to further
reduce τrs by ~ 30%. In conclusion, in newborns during
n= densidad
the active prolongation of the expiratory time constant is
such that the expiratory time is not sufficient for a com-
disorders. In: Taussig LM, Landau LI, inspiration active Crs and Rrs are both likely to be less plete deflation to the passive resting volume, Vr; hence,
editors. Pediatric respiratory medicine. New
York: Mosby 1999.
A B
C D
FIGURE
9–2. Changesand
MEB. Neuromuscular in rib cage
chest wallmorphometry
disorders. with growth. A, Posteroanterior and B, lateral chest radiographs of a 4-month-old infant. C,
 VAS del adulto y el Niño

chapter 16: special considerations in infants and children

often preferred. It is advanced in the midline over

the back of the tongue and over the anterior lip
Three-month old of the epiglottis. Pulling up then exposes the vocal
cords by pulling the epiglottis forwards. In larger chapter 16: special considerations in infants and children
children and adults, the tip of the laryngoscope
Table 16.1 Some physiological comparisons between infants and children. Values given are approximate
is placed in the vallecula in front of the epiglot-
Neonate (term) Infant (∼1 year) Child (∼8 years) Formula for calculation
tis, which is pulled forwards. The softWeight larynx in the 3.5–4 kg ∼10 kg ∼25 kg (Age + 4) × 2

Three-year old infant means that over-extension of theETneck tube size

is likely 3.0–3.5 mm 4.0–4.5 mm 6.0 mm Age/4 + 4 (after 1 year)
Daily fluid requirement Day 1: 60 mL.kg−1 ∼1000 mL.d−1 ∼1600 mL.d−1 For first 10 kg: 100 mL.kg−1
to kink the airway and needs to be avoided; the head Day 5: 120 mL.kg−1 (40 mL.hr−1 ) (64 mL.hr−1 ) For second 10 kg: 50 mL.kg−1
For rest: 20 mL.kg−1
should be kept in the neutral positionTidal when exam-
volume (mL) 20–30 50 125 4–6 mL.kg−1
ining the infant airway. Heart rate (beats.min−1 ) 110–150 100 70
Respiratory rate 40–60 30 20–25
Moving down the airway, the shape of the larynx
(breaths.min−1 )
in the child below the age of about Systolic eight blood
years is
pressure >60 80–90 105 90 + (2 × age)
(mm Hg)
conical, with the narrowest part lying at the level of
Adult
the cricoid cartilage. This is unlike the adult or older
child where the shape is cylindrical,formulae with the nar- designed to help with these cal- support, usually in the form of pressure support,
and tables
rowest part therefore lying at the level culations
of the (Table
vocal16.1). when spontaneously breathing through an endo-
Figure 16.1 Comparative anatomy of the upper airway.
Core cords.
Size has important implications in the lungs as tracheal tube.
As mentioned
Topics in Mechanical Ventilation previously, it lies three to four Core Topics in Mechanical Ventilation
well. Airway resistance follows Poiseuille’s law,
from capillary leak line the terminal bronchioles cervical vertebrae higher than in the adult, giving Control of breathing
8·l ·η
and alveolar ducts, further impeding alveolar oxy- a much more acute angle between theRoropharynx = (16.1) The infant’s control of breathing is less developed
r4
gen uptake. The damage caused by oxygen toxicity than in the older child. The newborn is thought to
and the glottis. from which it follows that resistance (R) is inversely be relatively insensitive to carbon dioxide,[1] par-
and ventilation of immature lungs probably con- In older children and adults, foreign bodies pass-
proportional to the fourth power of the radius (r) of ticularly the pre-term infant, and this is important
tributes to the altered lung structure seen in those ing beyond the vocal cords will passthe downairway;
intohalving
the the airway diameter will there- in the immediate post-natal period when respira-
fore increase resistance by 16-fold. It is important to
 Compliance o Distensibilidad distensibilidad pulmonar

Relaciona el volumen de un contenedor respecto a

la presión que genera en sus paredes distensibilidad torácica
Distensibilidad = Volumen / Presión

A mayor distensibilidad, menor elastancia

A menor distensibilidad, mayor elastancia distensibilidad toraco-

pulmonar

126 / Basic Mechanisms of Pediatric Respiratory Disease

en el RN y el lactante menor:
•menor CRF
•menor estabilidad
•reservorio deficiente
•homeostasis factible pero
inestable
•mayor riesgo de IR y PCR

ediatric Respiratory Disease

FIGURE 9–3. Respiratory system pressure-volume (PV) curves in the newborn and adult human. The slope of each curve at a given lung volume
represents the compliance at that volume. The solid curve in each diagram is the PV curve of the respiratory system (RS) and represents the sum of
the pressures resulting from the chest wall PV curve (left dashed line; CW) and the lung PV curve (right dashed line; L) at a given lung volume.
Passive end-expiratory lung volume (EEV) is represented by the point at which the solid curve crosses the zero pressure axis. It is relatively lower
in the newborn than in the adult because of the relatively high compliance of the newborn chest wall curve. (Reproduced with permission from
Agostoni E and Mead J.17)

EEV=CRF
THE RESPIRATORY MUSCLES
The diaphragm has three major inspiratory actions.28,29
First, by acting as a piston, the diaphragm decreases
intrapleural pressure, causing inward airflow through the
mouth and nose. Second, by increasing intra-abdominal
pressure, the diaphragm expands the lower rib cage. This
lower rib cage expansion occurs because a substantial por-
tion
m pressure-volume (PV) curves in the newborn and adult human. The slope of each curve at a given lung of intra-abdominal contents resides within the rib
volume
volume. The solid curve in each diagram is the PV curve of the respiratory system (RS) and represents the sum of
hest wall PV curve (left dashed line; CW) and the lung PV curve (right dashed line; L) at a given lung volume.
e (EEV) is represented by the point at which the solid curve crosses the zero pressure axis. It is relatively lower
because of the relatively high compliance of the newborn chest wall curve. (Reproduced with permission from
 Ecuación de Movimiento del gas Alveolar Unidad Funcional:“Alveolo
Capilar”
Vía Aérea: 16 SEG bronquios y bronquiolos
Δ Presión = Trabajo Resistivo + Trabajo Elástico
Alveolos: al nacimiento existe desarrollo heterogéneo, 10 millones aprox....acinos
W resistivo o impuesto = Flujo x Resistencia W elástico = Vt x elastancia

parénquima pulmonar menos distensible.

Δ Presión = Flujo x Resistencia + Vt / distensibilidad tejido vascular se musculariza y aumenta en masa con la edad.

crecimiento alveolar-capilar estrechamente ligados!!!

mucho ocurre en la vida post natal...

* Elastancia = 1 / distensibilidad

Ventilación colateral

ALVEOLAR MECHANICS ACUTELY INJURED LUNG

Poros de Khon
IN THE

Canales de Lambert

canales de martin

A = Alvéolo Fig. 8. Fung’s model of the alveolus. Each alveolus is in the shape
S = Septum alveolar of a tetrakaidecahedron, which is a 14-sided polyhedron (left). In a
group of adjacent alveoli (right) the tetrakaidecahedron in the cen-
D = Ducto alveolar ter is left void (dark) and serves as the alveolar duct, without af-
PK = Poro de Kohn fecting structural stability. (From Reference 11, with permission.)
PA = Rama de Arteria Pulmonar
ment of these structures has remained poorly understood.
This is a timely concern, since understanding the 3-dimen-
sional interactions is essential to understanding normal
alveolar mechanics and to the assessment of morphologi-
cal alterations that may lead to VILI. Elucidating the 3-di-
mensional anatomy and mechanics of the air sac is critical
Fig. 7. Alveolar walls (septa) described in terms of the septal edges, to understanding the pathogenesis of VILI.
junctions, and borders. E ! free edge. J ! septal junction. B ! Fung11 developed a mathematical model of the 3-di-
septal border. (From Reference 12, with permission.)
mensional structure of alveoli, based on 3 assumptions:
 Interdependencia Alveolar
Surfactante Alveolar

Capa líquida (lípidos y proteínas)

secretado a partir de las 28 SEG por los NT2

lecitina compuesto primitivo (17 SEG).

disminuye la tensión superficial en interface

aire/líquido

deficiente en RNPT

SDR y EMH relacionado con EG

Mead J, Takishima T, Leith D. Stress distribution in lungs: a model
of pulmonary elasticity. J Appl Physiol 1970;28(5):596–608 GENETICS OF LUNG DISEASE:
SURFACTANT PROTEIN B DEFICIENCY LAWRENCE M. NOGEE, MD

Relación V/Q

heterogénea a lo largo
del pulmón

condicionada por la
gravedad y presiones
pleurales

V/Q normal 0,8 - 1,2

 Shunt
CPT Espacio Muerto
O2 150 mmHg

CO2 0 mmHg

O2 150 mmHg

CO2 0 mmHg

O2 40 mmHg

CO2 45 mmHg

O2 100 mmHg

50% CPT
CO2 40 mmHg

O2 40 mmHg O2 40 mmHg O2 150 mmHg

CO2 45 mmHg CO2 45 mmHg
CO2 0 mmHg

O2 40 mmHg O2 100 mmHg

CO2 45 mmHg CO2 40 mmHg

Sangre venosa mixta

V/Q
VR
NORMAL

Aire
Egans, 2009 “Efectos de los cambios de la relación V/Q sobre la
inspirado

ventilación alveolar”
V/Q

Estabilización por Nitrógeno Saturación preductal objetivo después

914 SECTION V • Basic Therapeutics

FiO2 ! 100% FiO2 ! 21% (Room air)

del Nacimiento

1 minuto 60% - 65%

Alveolus
Alveolus
O2 ! 668
O2 ! 100
Co2 ! 40 2 minutos 65% -70%
Co2 ! 45 N2 ! 573
H2O ! 47 H2O ! 47
Total ! 760 Total ! 760
3 minutos 70% - 75%
Pulmonary Artery Pulmonary Artery

O2 ! 55
CO2 ! 45
O2 ! 40
CO2 ! 45
4 minutos 75% - 80%
H2O ! 47 N2 ! 573
Total ! 147 H2O ! 47
A B Total ! 705 5 minutos 80% - 85%
FIGURE 38-3 The development of atelectasis beyond blocked airways when breathing of 100%
O2 (A) and room air (B). In each case, the sum of the gas pressures in mixed venous blood
(pulmonary artery) is less than in the alveoli. The pressure gradient is much greater when
breathing 100% O2 (A), causing more rapid diffusion from the alveoli. Note: The gas pressures 10 minutos 85% - 95%
in the room air alveolus will change slightly over time, but the total will remain close to Pediatrics. 2010; 125:e 1340-1347
760 mm Hg.

priority. Avoiding depression of ventilation is discussed in
more detail later in this chapter.
Retinopathy of Prematurity
Retinopathy of prematurity (ROP), also called retrolental
fibroplasia, is an abnormal eye condition that occurs in
some premature or low-birth-weight infants who receive
supplemental O2. An excessive blood O2 level causes retinal
vasoconstriction, which leads to necrosis of the blood
vessels. In response, new vessels form and increase in
nitrogen levels decrease, the total pressure of venous gases
rapidly decreases. Under these conditions, gases that exist
at atmospheric pressure within any body cavity rapidly
diffuse into the venous blood. This principle is used for
removing trapped air from body cavities. Giving patients
high levels of O2 can help clear trapped air from the
abdomen or thorax.
This same phenomenon can cause lung collapse, espe-
cially if the alveolar region becomes obstructed (Figure
38-3). Under these conditions, O rapidly diffuses into the
 Control de la Respiración Control de la Respiración(2)
en el RN el SN es inmaduros. Durante el sueño REM

inestabilidad respiratoria transitoria en RNT ➭ inactivación de función laríngea.

inestabilidad respiratoria prolongada en RNPT ➭ hipotonía de la musculatura respiratoria

inmadurez de mecanismos quimiorreflejos.
➭ IC hipotónico
alteraciones mas evidentes durante sueño REM
➭ patrón paradojal evidente (asincronía toraco-abdominal)
mayor presencia de apneas y Sd. muerte súbita.
➭ RN mayor cantidad de tiempo en esta etapa del sueño
inmadurez de estructuras que controla.
➭ Respuesta deficiente a cambios en O2 y CO2
conducta frente a cambios en O2 y CO2:complejidad creciente que consiste en suspiros,
sobresaltos, agitación y excitación completa
➭aumento de los requerimientos ventilatorio

SLEEP AND RESPIRATORY CONTROL RONALD M. HARPER, PHD, DAVID GOZAL, MD

Postnatal Development of Respiratory Control, Basic Mechanisms of Pediatric Respiratory Disease

menor
hipotonía
desarrollo pulmonar Estrategias Ventilatorias
déficit de
Preservar CRF
surfactante sueño REM
CRF deficiente contrarrestar deficiencias antomofuncionales
del RN adaptarse y sobrevivir!!

compliance Enlentecimiento Espiratorio...Laringe

tórax diafragma pulmonar Modulación de la Frecuencia Respiratoria

inestable aplanado disminuida Uso de Musculatura Respiratoria en Espiración

 Función Laríngea
Enlentecimiento Espiratorio
musculatura laringea: intrinseca y extrinseca, pequeños, bajas demandas metabólicas

abducción Inspiratoria (CAP)

126 / Basic Mechanisms of Pediatric Respiratory Disease

En RN existe una aducción activa de las cuerdas bucales (TA)

Aducción por músculo tiroaritenoides actúa cuando flujo inspiratorio cede.

actividad glótica espiratoria disminuye con la edad.

aumenta el volumen espiratorio al final de la espiración por sobre la CRF pasiva.

sin la función laringea la CRF sería solo del 10% del total de la CPT v/s 40% adulto

bajo VEE: ATL e hipoxia

Función aductora cede durante sueño REM

FIGURE 9–3. Respiratory system pressure-volume (PV) curves in the newborn and adult human. The slope of each curve at a given lung volume
represents the compliance at that volume. The solid curve in each diagram is the PV curve of the respiratory system (RS) and represents the sum of
the pressures resulting from the chest wall PV curve (left dashed line; CW) and the lung PV curve (right dashed line; L) at a given lung volume.
Passive end-expiratory lung volume (EEV) is represented by the point at which the solid curve crosses the zero pressure axis. It is relatively lower
in the newborn than in the adult because of the relatively high compliance of the newborn chest wall curve. (Reproduced with permission from
Agostoni E and Mead J.17)

378 / Basic Mechanisms of Pediatric Respiratory Disease

THE RESPIRATORY MUSCLES
adults; short expiratory times limit the degree of lung The diaphragm has three major inspiratory actions. 28,29

First, by acting as a piston, the diaphragm decreases

emptying that can occur before Actividad
the next inspiration. Diafragmática en
intrapleural pressure, causing inward airflow through the
mouth and nose. Second, by increasing intra-abdominal
Active laryngeal adduction is particularly prominent pressure, the diaphragm expands the lower rib cage. This

in newborns within the first few hoursEspiración

lower rib cage expansion occurs because a substantial por-
after birth tion of intra-abdominal contents resides within the rib
(England, unpublished observations). During this time,
the positive subglottic pressures generated with active
adduction contributeestrategia ventilatoria of lung air
to the establishment
volume and promote fluid clearance.
retrasar
Expiratory activity flujos
of laryngeal
active prolongationexhalatorios
ofadductors inaconstant
FIGURE 9–4. Elevation of end expiratory lung volume (EEV) by
the respiratory system time adults (τ). The
solid line is the expiratory limb of the tidal flow volume curve. The
has been found in some, but slope not all, investigations. The
FIGURE 27–1. Moving time averages of the diaphragm (DIA) and través de una
of the solid
represents contracción
line (volume/flow)
the active
has the units of seconds and
expiratory time constant (τ ). The slope of the

posterior cricoarytenoid (PCA) and thyroarytenoid (TA) muscles during discrepancies between studies dottedmay bethepartially
line represents explained
passive time constant of the system (τ )
exp

excéntrica delanddiafragma
rs

following an end-inspiratory occlusion, which activates the Hering-

wakefulness and non-REM and REM sleep, recorded in a 28-day-old by the use of anesthetics (see the
Breuer reflex section
therefore relaxes“Influence
the respiratory muscles. of The
difference between the two slopes (τ >τ ) is caused by the slowing
exp rs

dog pup. An upward deflection reflects increased activity of the mus- Pharmacologic Agents and Alcohol”). Expiratory
of expiration by active respiratory activity
muscle braking. These lines inter-
sect at the passive relaxation volume (Vr). The volume difference
FIGURE 9–5. Postinspiratory activity of the diaphragm. The sharp
spikes are cardiac artifact. Diaphragmatic electromyogram (EMG ) of

evitar elmaintenance
vaciado pulmonar
DI

cle. The PCA has an increased activity during inspiration coincident of the thyroarytenoid muscle is
between Vrpresent
and the active flow
of functional
in adult
volume rats
curve EEV and
reflects active
residual capacity (FRC). (Reproduced with
breaths 3 and 4 shows electrical activity after inspiration ends, which
slows expiratory airflow. (Reproduced with permission from Kosch PC
with diaphragmatic contraction, whereas the TA has phasic expiratory humans during quiet breathing in wakefulness.20,21 The and Stark AR. )
permission from Mortola JP and Saetta M. ) 18 19

activity. Note the decrease in tonic or expiratory activity of the PCA mechanical effect of this activity is the same as in infants:
during non-REM sleep as compared with wakefulness and the loss of preservar
an increased expiratory resistance CRF and a slowing of expi-
phasic expiratory activity in the TA during REM. ratory airflow. Thus, expiration cannot be considered a DEVELOPMENT OF THE THORACIC CAGE JULIAN ALLEN, MD, KAREN W. GRIPP, MD
Pediatric Respiratory Disease.Chernick-Mellins, 2002

totally passive process because both laryngeal adduction

ing inspiration and appears to act synergistically with the and postinspiratory diaphragmatic activity modulate the
abductor.8,13,14 If the vocal cords were not actively tautened rate of lung emptying. However, these activities are far
and separated during inspiration, the negative pressure more prominent in infants than in adults.
generated in the airway during diaphragmatic contraction In addition to the phasic activation of the PCA during
 Modulación de la Frecuencia
Respiratoria VA de conducción y complejo
SNC inmaduro
alveolo/capilar
“Drive Respiratorio”
estrategia ventilatoria

aumentar volumen inspiratorio

En resumen: la Falla Respiratoria es
FR elevadas particularmente común en RN y
lactantes debido a la inmadurez en 3
exhalaciones cortas áreas

reflejo Hering-Breuer

modular CRF inestabilidad de la pared

DEVELOPMENT OF THE THORACIC CAGE JULIAN ALLEN, MD, KAREN W. GRIPP, MD
torácica y fuerza muscular
Pediatric Respiratory Disease.Chernick-Mellins, 2002

A considerar...
RNPT, RN y lactantes presentan un sistema respiratorio inmaduro.

madurez toraco-pulmonar se alcanza a los 10 años aprox.

mecanismos de control respiratorio difieren según edad.

estrategias ventilatoria pretenden contrarrestar deficiencias

anatomo-funcionales

RN presentan menores reservas funcionales.

mayor predisposición a: IR, SDR, PCR

definitivamente un niño no es un adulto en miniatura...